Nurse Anesthetists Commend Aetna's Delay of Policy

Action Encourages Early Detection of Colon Cancer to Save Lives

WASHINGTON, D.C. -- The announcement by Aetna that it will restore coverage for anesthesia services that assure patients the most effective, comfortable and efficient delivery of life-saving colonoscopies was lauded by the 37,000-member American Association of Nurse Anesthetists (AANA), which had requested that the health insurance giant reverse its recent policy change denying such coverage.

"Colon cancer kills, early detection saves lives, and the most reliable method for early detection is colonoscopy," said AANA president Wanda O. Wilson, CRNA, PhD. "Patients and physicians agree that the safest and most comfortable colonoscopy is delivered with monitored anesthesia care (MAC) provided by a Certified Registered Nurse Anesthetist (CRNA) or other anesthesia professional. As nurse anesthetists, our primary interest lies in improving patient safety, comfort, and access to high quality care.

"By restoring coverage for MAC as AANA had requested, Aetna is making colonoscopies safer and more accessible for patients," said Wilson. "When a major insurer like Aetna says it will cover the best colonoscopy method, it hopefully will encourage more adults to undertake this life-saving procedure. It should also lead other health plans in covering or continuing to cover GI endoscopy MAC."

CRNAs provide the lion's share of MAC services in the United States for patients undergoing colonoscopies in hospitals, ambulatory surgical centers, and physician offices, working in most instances directly with the surgeon performing the procedure.

In December 2007, Aetna proposed denying coverage of MAC by anesthesia professionals in routine GI endoscopy cases, effective April 1, 2008. On behalf of nurse anesthetists, Wilson wrote to Aetna chief Medical officer Troyen Brennan, MD, MPH, and urged Aetna to withdraw the policy. In her letter, Wilson stated that "(i)t erects new barriers between patients and the safest, most comfortable, most thorough and efficient method for delivering life-saving diagnostic GI endoscopy screenings... The value of having a CRNA provide propofol MAC for GI endoscopy is that it enables a more thorough, higher-quality procedure in less time, a distinctly superior outcome relative to other methods of sedation for GI endoscopy."

Wilson also shared her letter with representatives of the American Cancer Society. Some 153,000 Americans were diagnosed with colorectal cancer in 2007. Five-year survivability of early-detected colorectal cancer exceeds 90 percent, but only 39 percent of colorectal cancer is detected early. "Clearly, too few people avail themselves of GI endoscopy screening, on account of several factors -- including discomfort and out-of-pocket cost," Wilson wrote.

In a February meeting, AANA and Aetna representatives carefully examined the evidence Aetna was relying on to make policy. Included were data showing that patients undergoing colonoscopy with propofol rated their procedures as being more comfortable (81 percent vs. 47 percent). FDA labeling requires propofol to be administered by general anesthesia specialists such as CRNAs. The data also showed that patients were more likely to report that they felt no discomfort (84 percent vs. 66 percent) and had a shorter recovery time (12 min. vs. 93 min.).^{1, 2}

"We respect that Aetna has expressed concerns about propofol MAC for colonoscopies costing too much," said Wilson. "Though insurers have reportedly stated that anesthesiologists charge up to $1,000 for this service, such a figure is two to three times what CRNAs report from other private payers, and about eight times Medicare's fee. We realize Aetna hopes that new technology can further reduce costs. With the Institute of Medicine reporting that today's anesthesia is 50 times safer than in the early 1980s, America's CRNAs have long been on the forefront of technological change that improves patient safety.

"Using CRNAs to provide MAC for colonoscopies represents a win-win for patients and health plans alike," said Wilson. "We enable an uncomfortable procedure to be delivered more comfortably, more effectively, and more efficiently, with greater patient satisfaction than currently available alternatives. With a CRNA at the head of the table, the surgeon can focus full attention on the GI procedure. The peace of mind that colonoscopies can be safe, comfortable, and thorough with CRNA care should encourage more people to undertake this life-saving screening.

"Aetna's business is in its millions of health plan members and its shareholders," Wilson concluded. "Our business as CRNAs is in patient comfort and safety. Clinicians and insurers should keep open the lines of communication in the interests of the people we serve."

References
1. Paspatis GA, Manolaraki M, Xirouchakis G, Papanikolaou N, Chlouverakis G, Gritzali A. Synergistic sedation with midazolam and propofol versus midazolam and pethidine in colonoscopies: a prospective, randomized study. Am J Gastroenterol 2002;97: 1963-1967.

2. Reimann FM, Samson U, Derad I, Fuchs M, Schiefer B, Stange EF. Synergistic sedation with low-dose midazolam and propofol for colonoscopies. Endoscopy 2000;32:239-244. Cited in Cohen LB, Delegge MH, et al. AGA institute review of endoscopic sedation. Gastroenterology 2007;133:675-701.

Source: American Association of Nurse Anesthetists

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